Provider Demographics
NPI:1770617029
Name:WATKINS, MARK G (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:WATKINS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 SWAN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1104
Mailing Address - Country:US
Mailing Address - Phone:419-490-6448
Mailing Address - Fax:
Practice Address - Street 1:5701 SWAN CREEK DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1104
Practice Address - Country:US
Practice Address - Phone:419-490-6448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-0090772080P0205X
OH34.009077208D00000X
MI5101016254390200000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH06807OtherPARAMOUNT
MI1770617029Medicaid
OH9666061OtherAETNA
OH000000547496OtherANTHEM
OH2801187Medicaid
OH7377851Medicare PIN